Second-look laparotomy for ovarian cancer

Intraperitoneal radioactive phosphorus (32P) versus observation after negative second-look laparotomy for stage III ovarian carcinoma: a randomized trial of the Gynecologic Oncology Group

PURPOSE

The objectives of this prospective randomized study of consolidation therapy were to evaluate recurrence-free survival (RFS), overall survival (OS), and the morbidity of intraperitoneal (IP) chromic phosphate suspension (32P) therapy in patients with stage III epithelial ovarian carcinoma who have no detectable evidence of disease at the second-look laparotomy (SLL) procedure after primary chemotherapy.

PATIENTS AND METHODS

In a multi-institution clinical cooperative trial, 202 eligible patients with a negative SLL were randomly selected to receive either 15 mCi IP 32P (n = 104) or no further therapy (NFT; n = 98).

RESULTS

With a median follow-up of 63 months in living patients, 68 patients in the IP 32P group (65%) and 63 patients in the NFT group (64%) have developed tumor recurrence. The relative risk of recurrence is 0.90 (IP 32P to NFT) (90% confidence interval [CI], 0.68 to 1.19). The 5-year RFS rate is 42% and 36% for the IP 32P and NFT groups, respectively; the difference is not statistically significant (log-rank test, P =.27). There was no statistically significant difference in OS (P =.19). The relative risk of death is 0.85 (IP 32P to NFT) (90% CI, 0.62 to 1.16). Sixteen patients (8%) experienced grade 3 or 4 adverse effects, with eight in each respective group.

CONCLUSION

Intraperitoneal chromic phosphate did not decrease the risk of relapse or improve survival for patients with stage III epithelial ovarian cancer after a negative SLL. Despite complete pathologic remission at SLL after initial surgery and platinum-based chemotherapy, 61% of stage III ovarian cancer patients had tumor recurrence within 5 years of negative SLL. This indicates a need for more effective initial therapy and further studies of consolidation therapy.

Current management of epithelial ovarian carcinoma: a review

Epithelial carcinoma of the ovary is the most lethal of gynaecological malignancies and it affects about one in 70 women in developed countries. Over 75% of women with the disease have tumour spread beyond the pelvis at the time of diagnosis, and their treatment requires the appropriate use of surgery and chemotherapy. The strategies used in the treatment of ovarian cancer are constantly evolving. An overview of current treatment regimens and their evolution is provided, with particular emphasis on the interdependence of surgery and chemotherapy in the optimal management of the disease.

Lymph node sampling in patients with epithelial ovarian carcinoma

Lymph node sampling is part of the FIGO staging of patients with ovarian carcinoma and is usually part of a meticulous second look operation. We analyzed the primary lymph node status of patients and compared this to the lymph node status at second look operation. From 3/86-3/91, 97 patients with epithelial ovarian tumors were treated at this institution. Seventy-one of the 97 patients (73.2%) had lymph node sampling at primary surgery. Thirty of the 71 patients had positive lymph nodes (42.2%) and 41 patients were lymph node negative (57.8%). Of the initial 97 patients, 58 were eligible for second look operation (59.8%), and 48 of these patients had lymph nodes sampled at second look operation. Nine of the 48 patients had positive lymph nodes (18.7%) and 39 had negative lymph nodes at second look operation (81.3%). Of the patients with negative lymph nodes at primary surgery, 25 patients had second look operation and 24 of these patients had lymph node sampling at second look operation. All patients with negative lymph nodes at primary surgery had negative lymph nodes at second look operation. Of the 30 patients with positive lymph nodes at primary surgery, 12 underwent second look operation. Four patients had persistent positive lymph nodes and 8 patients had negative lymph nodes. Our data suggest that patients with negative lymph nodes at primary surgery are unlikely to have positive lymph nodes at second look operation. Therefore, we believe that lymph node sampling under these circumstances is unnecessary.

Prognostic factors for recurrence following negative second-look laparotomy in ovarian cancer patients treated with platinum-based chemotherapy

Prior studies of the risk of recurrence following negative second-look laparotomy have included patients treated with a variety of chemotherapeutic regimens, including nonplatinum regimens. We have examined the long-term outcome and risk factors for recurrence among a homogeneous group of platinum-treated patients. During the years 1978-1987, 91 patients at Memorial Sloan-Kettering Cancer Center had a negative second-look laparotomy following platinum-based chemotherapy for epithelial ovarian cancer. The mean age at diagnosis was 57 years, with a range of 30 to 79. Distribution by stage was as follows: I, 10; II, 18; III, 57; IV, 6. The mean number of cycles of platinum prior to second-look surgery was 6.3. The mean number of biopsies taken at negative second-look laparotomy was 12. Lymph node biopsies were done in 47/91 (52%) of patients. Median follow-up from the date of second-look laparotomy was 54.6 months among survivors. Forty of ninety-one patients (44%) have had recurrence, almost 40% of which were outside the peritoneal cavity. The mean interval from negative second-look laparotomy to recurrence was 24 months (range, 2-70 months). By multivariate analysis the risk of recurrence was significantly related to stage (P = 0.017), histologic grade (P = 0.041), and the amount of tumor remaining after the first operation for ovarian cancer (P = 0.015). Recurrence by stage was as follows: stage I, 1/10 (10%); stage II, 5/18 (28%); stage III, 31/57 (54%); stage IV, 3/6 (50%). Recurrence by grade was as follows: grade 1, 4/18 (22%); grade 2, 11/28 (39%); grade 3, 25/45 (56%). There was no relationship between the risk of recurrence and the number of cycles of platinum, the number of biopsies performed at second-look, or the number of months from primary surgery to second-look. Patients having negative second-look laparotomy following platinum-based chemotherapy for advanced epithelial ovarian cancer have a substantial risk of recurrence, particularly within the first 3 years. Such patients should be offered participation in clinical trials of consolidation therapy directed against both intraperitoneal and extraperitoneal disease.

Prognosticators of second-look laparotomy findings in patients with epithelial ovarian cancer

Prognosticators of outcome at second-look laparotomy (SLL) were evaluated in 49 patients with epithelial ovarian carcinoma undergoing SLL. Residual tumor volume was found to be the most significant prognosticator of outcome, with initial tumor stage being of secondary importance. Grade of tumor played no role in outcome at SLL. The results of the study led us to the conclusion that the second-look procedure may be safely omitted in stage I patients. The importance of optimal cytoreduction during primary surgery was stressed.

Chemotherapy by the intravenous and intraperitoneal routes combined in ovarian cancer

Intraperitoneal (ip) administration allows delivery of concentrations of cytotoxic drugs to the site of tumor development that could not be attained by the intravenous (iv) route. Rather than leaving ip delivery systems (Tenckhoff catheter, Port à Cath, etc.) in position for several months, with the attendant risk of complications, we prefer to use a simple needle for lumbar puncture and leave it in place between 1 and 2 hr at each infusion of chemotherapy. Results observed at second-look laparotomy in 31 patients with stage III (FIGO) common epithelial carcinoma, treated from January 1980 to December 1986, are reported after six to ten courses of ip and iv chemotherapy combined. In five patients in whom complete surgical excision had been possible, there was still complete remission (CR). In 26 patients in whom initial surgical excision had been incomplete, there was complete remission in 20 (76%). In the other 6 cases, there were small residual masses (incomplete remission), which could readily be excised by the surgeon. Following second-look laparotomy, these 6 patients received ip maintenance chemotherapy for a further 6 months. During follow-up periods of 22 to 105 months (average 45 months), 8 recurrences were observed (4 of them died); 23 of 31 patients are disease free. At 4 years, actuarial survival was 81.5% and actuarial disease-free survival was 66.2%.

Factor analysis of false-negative second-look laparotomy

From January 1976 through December 1987, 155 patients with ovarian epithelial malignancy underwent a second-look laparotomy. Seventy-seven (50%) had a negative second-look. Recurrence after negative second-look occurred in 15 patients (19.5%). Of the factors analyzed, serous histology and residual disease after initial laparotomy were found to be of significance. Grade of tumor, stage, and ascites were not found to be of significance.

Continuous hyperthermic peritoneal perfusion for the treatment of peritoneal dissemination in gastric cancers and subsequent second-look operation

A total of 31 patients with gastric cancer showing peritoneal dissemination received continuous hyperthermic peritoneal perfusion (CHPP) in combination with the administration of cisplatin (CDDP) and mitomycin C (MMC). The authors developed a new special device named the peritoneal cavity expander (PCE) for sufficient perfusion and direct temperature measurement in the peritoneal cavity. As complications of CHPP three patients presented with bone marrow suppressions (leukocytes less than or equal to 3000/mm3 and/or platelets less than or equal to 30,000/mm3): one, leakage of intestinal anastomosis; one, intestinal perforation; and one, acute renal failure. But none of them was lethal. Twelve of 31 patients who had received CHPP during the initial operation underwent second-look operation (SLO) for the assessing the effects of CHPP and for resecting residual or recurrent tumors. Among 12 patients who received SLO complete response (CR) was observed in four patients, partial response (PR) in one, no change (NC) in three, and progressive disease (PD) in four, with the overall response rates (%CR + %PR) standing at 41%. Two-year survival rate of the complete and partial responders was 50%, which was significantly higher than 0% of the other responders (NC + PD). The survival curves of the two groups were significantly different (P less than 0.05, generalized Wilcoxon test). These results supported that CHPP was well tolerated and effective for the treatment of patients with peritoneal dissemination in gastric cancer when combined with anti-cancer drugs having synergism with hyperthermia. Since the outcome of SLO was one of prognostic factors it was important to follow up these patients by SLO.

Whole abdominal irradiation following chemotherapy in patients with minimal residual disease after second look surgery in ovarian carcinoma

From January 1981 through December 1985, 65 patients with epithelial carcinoma of the ovary were treated with the following protocol: surgery, combination chemotherapy, second-look surgery documenting tumor less than or equal to 2 cm, and whole abdominal irradiation. Chemotherapy consisted of a combination of cyclophosphamide, adriamycin, and cisplatinum in 89% of the patients. The median number of cycles was eleven. Second-look surgery documented no residual tumor in 23 patients, microscopic disease in three patients, and macroscopic disease less than or equal to 2 cm in 39 patients. Whole abdominal irradiation was given with an open field technique up to 20 Gy without renal or hepatic shield. A pelvic boost of 15-30 Gy was subsequently added in 17 patients with macroscopic disease in the pelvis at the time of second-look surgery. Fifteen patients received complementary chemotherapy mostly hexamethylmelamine. All but two patients completed whole abdominal irradiation: one refused further radiotherapy after 3 Gy and one developed disease progression with bowel obstruction after 1 Gy. The median follow-up was 69 months. The 3-year and 6-year no evidence of disease survival rates were 60% (95% CI: 48-71) and 33% (95% CI: 21-46), respectively. The 3-year and 6-year recurrence rates were 33% (95% CI: 22-45) and 54% (95% CI: 40-67), respectively. The 3-year and 6-year metastasis rates were 22% (95% CI: 13-34) and 43% (95% CI: 30-58), respectively. A multivariate analysis showed that residual disease after second-look surgery was the only significant prognostic factor with a relative risk of death or local or distant failure of 4.2 (95% CI: 1.9-9.5, p less than 10(-4)). Two patients developed mean-term gastrointestinal complications (small bowel obstructions requiring surgery). Survival remains poor with high level of failure even with aggressive multimodal treatment.

The influence of cytoreductive surgery on progression-free interval and survival in epithelial ovarian cancer

In 1980, Dr George E. Moore published an editorial in Surgery, Gynecology and Obstetrics entitled 'Debunking debulking'. He included advanced ovarian cancer in his personal list of 'faulty' debulking procedures. Some of hist statements have merit. He contends that overly aggressive procedures that leave microscopic tumour cells that will soon grow and kill the patient are unindicated. He further points out that one cubic centimetre of tumour will contain approximately a billion cells. However, there are factors in ovarian cancer that should cause one to take exception to Dr Moore's statement. First, there is good evidence that the use of cisplatin-based multidrug chemotherapy may eradicate microscopic tumour deposits in a significant number of patients. Secondly, even multiple aggregates of tumour with a billion or more cancer cells can be eradicated in some cases, and in others can be reduced sufficiently to allow significant palliation. In evaluating the information which has been reviewed in this discussion of cytoreductive surgery for advanced ovarian cancer, it is apparent that cytoreductive surgery is not only indicated, but mandated in many facets of the management of ovarian cancer. The following principles seem to be supported by the existing literature: 1. Current diagnostic techniques do not enable us to diagnose ovarian cancer while still confined to the ovary. Therefore, in the immediate future we will still encounter a large number of patients with advanced disease. 2. The number of complete clinical responses and the number of complete pathological responses (negative second-look surgical reassessments) are greatest in those patients who begin adjunctive therapy with minimal residual disease. 3. Median duration of survival is longer, and long-term survival more likely, in those patients giving complete clinical or complete pathological responses. 4. Some patients appear to benefit from secondary cytoreductive surgery. However, at the present time, evidence of benefit from secondary cytoreductive surgery appears to be limited to those patients who have responded to adjunctive therapy and are found to have residual disease at surgical reassessment. There is no good evidence to support secondary cytoreductive surgery as an 'interval' procedure or its use in patients with progression on primary adjunctive therapy. This development of better chemotherapy regimens, such as cisplatin-based chemotherapy, has resulted in a greater need for effective primary cytoreductive surgery as it is apparent that, on utilizing these new regimens, better results are obtained in patients with minimal residual disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Primary chemotherapy and the role of second-look laparotomy in non-dysgerminomatous germ cell malignancies of the ovary

In view of the rarity of germ cell tumors of the ovary, it is not surprising that little information exists about the indications for and significance of findings at second-look laparotomy in patients with these tumors. For this reason, we have reviewed 16 patients who received primary chemotherapy for malignant germ cell tumors of the ovary at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1976 and 1983. Eleven of them underwent a second-look laparotomy after completion of their therapy. Primary therapy consisted of surgery, usually unilateral oophorectomy, and cis-platinum-based VAB chemotherapy. The histologic diagnoses were six immature teratomas, five endodermal sinus tumors, four mixed germ cell tumors, and one nongestational choriocarcinoma. Stage distribution was as follows: Stage IA, eight patients; Stage IC, one patient; Stage IIA, one patient; Stage III, four patients, and unstaged, two patients. The ages ranged from 15 to 56 years, with the mean of 29 years. All of the 11 patients undergoing second-look laparotomy were found to be free of disease. They are alive and have been continuously free of disease from 9 to 77 months (mean 39 months). This paper discusses primary chemotherapy and the role of the second-look laparotomy and suggests its value in modifying treatment, predicting cure, and safely stopping therapy in patients with germ cell malignancies of the ovary.

Is routine second-look laparotomy for ovarian cancer justified?

Thirty-nine patients with epithelial ovarian malignancy underwent second-look laparotomy (2LL), as part of their plan of management at the Johannesburg University Hospital. Twenty-eight patients (71.8%) were found to have no gross or microscopic evidence of disease. Only 1/12 (8.3%) of patients with initial Stage I disease had evidence of persistent disease and after a median follow-up of 53 months (range 29-77) after 2LL, the remaining 11 remain free of relapse. Second-look laparotomy is regarded as unjustified in this subgroup of patients. Twenty-nine percent of the patients with advanced disease (Stage III and IV) who were disease-free at 2LL subsequently developed recurrent disease and died. In this group 2 additional patients died of nonmalignant disease. All 3 of the patients with original Stage II disease were disease-free at 2LL, but subsequent recurrence developed in 1 patient. On the basis of the findings in this study and evidence in the literature, the practice of submitting patients who are in complete clinical remission to 2LL as part of their management plan is questioned and challenged.

Second-look laparotomy in epithelial ovarian carcinoma. Prognostic factors associated with survival duration

This article that reports on 70 consecutive patients is one of only a few studies of advanced ovarian cancer that have attempted to define predictive factors associated with survival duration after second-look laparotomy. As in many other investigations, several factors have been analyzed for predicting second-look outcome. The prognostic variables analyzed in this study included age, stage, histologic grade, residual disease status after initial surgery, and type (cisplatin versus no cisplatin) and number of cycles of chemotherapy. Only stage (P = 0.002) and optimal disease (less than 2 cm residual tumor size) after initial surgery (P less than 0.001) were significantly associated with the absence of disease at second-look laparotomy, and both were significant predictors of second-look outcome in a multivariate logistic regression model. Their impact on actuarial survival after second-look laparotomy diminished, however. Actuarial survival after second-look laparotomy was associated with residual tumor size at second-look surgery (P = 0.02). According to second-look findings, the 3-year actuarial survival rates and standard errors were as follows: no pathologic evidence of disease, 80.7% +/- 13.4% 3-year survival; microscopic disease plus less than or equal to 2 cm residual disease, 49.1% +/- 13.1% survival; and gross residual disease (i.e., greater than 2 cm maximum tumor diameter), 29.5% +/- 11.4% survival. We also examined the effect of extensive tumor resection at second-look laparotomy on survival for patients with greater than 2 cm gross residual disease. Optimum resection (less than 2 cm residual tumor mass) resulted in significantly greater survival than suboptimum resection (P less than 0.001). This strongly suggests that there is a survival advantage associated with optimum resection at second-look laparotomy.

Intraperitoneal chromic phosphate therapy after second-look laparotomy for ovarian cancer

Between 1973 and 1985, 118 patients in clinical remission after initial surgery and postoperative chemotherapy for epithelial ovarian carcinoma underwent second-look laparotomy at the University of North Carolina. No evidence of disease (NED) was found in 57 of these patients; 43 patients received 15 mCi of radioactive chromic phosphate (32P) suspension given intraperitoneally in the immediate postoperative period. In 29 other patients, only microscopic or minimal residual disease (nodules less than 2 cm in size) was found, seven received 32P alone, ten received 32P and further chemotherapy, and 12 received chemotherapy alone. The 4-year postsecond-look survival of the patients with NED at second-look was 89% for those receiving 32P and 67% for those who had not. The respective figures for patients with minimal residual disease at second-look are 59% versus 22%. Irrespective of treatment, a group at high risk for failure after negative second-look laparotomy has been identified; those with an initial International Federation of Gynecology and Obstetrics (FIGO) stage greater than I and histologic grade greater than 1. A comparison of our data with 18 previously published series, indicates that use of postsecond-look intraperitoneal 32P can improve the progression-free interval, and possibly overall survival, of patients with NED or minimal residual disease without adding significant complications.

Prognostic factors in borderline and invasive ovarian tumors of the common epithelial type

Present reports show that surgical factors, response to therapy and histological criteria are important for predicting the prognosis of patients with common epithelial types of ovarian tumors. Newer techniques such as morphometry, DNA cytometry, immunological and immunopathological techniques may help to define prognostic factors even more accurately. As a result, these recently developed methods may enhance the value of well-established classical predictors of the outcome in case of borderline or invasive ovarian tumour.

Use of second-look laparotomy in the management of patients with ovarian epithelial malignancies

Between June 1976 and January 1986, 94 evaluable patients with stage I-IV disease underwent second-look laparotomy as part of their treatment for ovarian epithelial carcinomas. Stage and residual tumor size after initial debulking surgery demonstrated a significant association with absence of disease at reexploration. Forty-nine patients (52%) had no evidence of disease at second-look laparotomy. Thirty patients (32%) had macroscopic residual tumor, and 15 patients (16%) had microscopic disease at reexploration. Patients with a negative second-look laparotomy had an excellent prognosis; uncorrected 2- and 5-year survival rates exceed 90%. None of the patients with stage I or II disease developed recurrent tumor after a negative second-look laparotomy. However, 7 of the 25 (28%) patients with stage III disease and a negative second-look have demonstrated recurrent carcinomas. Recurrences were documented from 15.4 to 51.7 months after second-look laparotomy and were located within the abdominal cavity. Life table methods demonstrated improved survival for patients with microscopic disease as compared to those with gross tumor at second-look survey. Both groups had similar mean patient ages and tumor stage distributions. Patients with microscopic residual disease had uncorrected 2- and 5-year survival rates of 76 and 64%. The 2-year uncorrected survival rate for patients with gross tumor at second-look laparotomy was 25%. Thirty patients with macroscopic disease at second-look laparotomy underwent a repeat attempt at tumor debulking. Seventeen patients completed second-look surgery with residual disease less than 1 cm in maximum dimensions. Life table methods demonstrated improved survival when residual disease was less than 1 cm. Regardless of residual tumor size after reexploration, patients with gross tumor had a worse survival than those with microscopic disease.

Another look at the second-assessment procedure for ovarian epithelial carcinoma

Over a 10-year period, 65 of 196 patients (33%) with ovarian epithelial malignancy, previously treated with chemotherapy, had a second-look operation if the disease was clinically absent. All procedures were done by one of three gynecologic oncologists, and 48% of the patients had a positive second-look procedure. Of patients with original stage I, II disease, 25% had a positive second-look operation, contrasting with 61% of patients with stage III, IV. Significant perioperative morbidity occurred: one patient had intraoperative vascular collapse; 15% had prolonged ileus; 17% had small bowel resections at the time of the second-look operation or in the postoperative period. Of all patients with negative second-look operations, 24% have had recurrent disease from 5 to 23 months after the procedure. These recurrences were in the liver or distant sites in 63% of the patients. Second-look operations, if still indicated by negative noninvasive techniques, should be performed in tertiary care centers under study situations in a standard fashion.

Use of indium-111-labeled OC-125 monoclonal antibody in the detection of ovarian cancer

This is a preliminary study to evaluate the utility of using the monoclonal antibody (CO-125) labeled with indium-111 to image recurrences of ovarian cancer. This technique has been investigated in 23 patients with ovarian cancer and the results have been compared with blood OC-125 levels, CT scans, and findings at second-look surgery. Following infusion of 1 mg of F(ab')2 fragments (1-2 mCi 111In), quantitative SPECT and planar imaging was obtained daily for 72 hr along with analysis of serum. The nuclear medicine scans of the tumor site recurrences were technically excellent. When compared to second-look laparotomy, there were 2 true negatives, 2 false positives, 14 true positives, and 2 false negatives by nuclear imaging. CT scans correlated less well with surgery, but serum OC-125 levels correlate more closely with nuclear scans and second-look surgery. Those with multiple small metastatic implants showed a pattern of diffuse uptake which increased with time, whereas those with nodal or larger recurrences showed a more focal uptake. The combination of favorable biodistribution and positive images, especially in patients with normal antigen levels and negative CT scans, suggests a role for OC-125 monoclonal antibody imaging in their clinical management. However, further investigation is needed to determine whether nuclear scans can replace second-look surgery. If it can show that enough 111In-labeled antibody accumulates in the tumor site to justify radioimmunotherapy, then 90Y (a pure beta emitter) could be exchanged for 111In. This is potentially a method of radioimmunotherapy for recurrent ovarian carcinoma.

Abdominopelvic irradiation for stage II-IV ovarian carcinoma patients with limited or no residual disease at second-look laparotomy after completion of cisplatinum-based combination chemotherapy

Abdominopelvic irradiation was given to 18 stage II-IV ovarian carcinoma patients who completed cisplatinum-based combination chemotherapy, were in complete clinical remission, and who underwent second-look laparotomy. The survival as well as the progression-free interval (PFI) was significantly longer in patients with a negative second-look laparotomy than in those with limited residual disease at this operation. Abdominopelvic irradiation was not effective in patients with limited residual disease at second-look laparotomy (3 year survival--34.3% and median PFI from second-look laparotomy--4.8 months). Even in patients with a negative second-look laparotomy the median PFI was only 13 months from this operation and the 3-year survival was 87.5%. The results were similar to other comparable series in which no treatment was administered to patients with a negative second-look laparotomy.

A review of second-look laparotomy for ovarian cancer

One hundred twenty-seven patients underwent second-look laparotomies from July 1969 to June 1982. To be included in this report they must have met the following criteria: a documented ovarian neoplasm; previous surgery; adequate chemotherapy for cessation if no disease was found; and no X-ray, chemical, or clinical evidence of disease including an exam under anesthesia. Forty-one percent had residual disease at second-look laparotomy. The original stage and the percentage of tumor debulked at initial surgery were inversely related to the likelihood of finding residual disease. Age, histologic type and grade, and type of chemotherapy did not show a significant relationship with the likelihood of disease persisting. Recurrent tumor was subsequently detected in 16% of patients who had been found to be free of disease at second-look laparotomy. Of thirty stage III and IV patients treated with combinations containing cis-platinum, 10 (33%) had recurrences. This rate of recurrence was significantly greater than the 17.6% recurrence rate in 17 patients with Stage III and IV disease whose chemotherapy consisted of single alkylating agents or with combinations without cis-platinum. Twenty patients underwent a third-look laparotomy after completion of additional chemotherapy. Nine were found to have no residual disease. Two of the nine (22%) subsequently had recurrence of disease. Three of the eleven patients with persistent disease at the time of a third-look laparotomy underwent a fourth-look laparotomy. All were found free of disease and none have recurred. Six (55%) of those with persistent disease at the third-look laparotomy have died despite continued therapy. The ability to successfully treat some patients with persistent disease continues to be a justification for the use of a second-look laparotomy. However, the high rate of recurrence after cessation of treatment following the finding of no residual disease raises the question of whether it is appropriate to discontinue all therapy at this time.

Second-look laparotomy in ovarian cancer: evaluation of pathologic variables

From 1977 through 1982, 135 patients with ovarian cancer, having a mean age of 53.7 years and no clinical evidence of disease after approximately 1 year of treatment, underwent a "second-look" laparotomy. Of the 135 patients, 58 (43%) had histologic confirmation of disease at the second-look procedure. Persistent disease was positively correlated with the original stage and negatively correlated with the extent of the original reductive surgery. The original histologic grade or cellular subtype did not significantly influence the findings at reexploration. Patient survival, as judged by percentage of patients alive 3 years after the second-look laparotomy, was dependent on the following surgical/pathologic parameters: tumor size at reexploration, peritoneal cytologic features, residual tumor after reexploration, and histologic grade.

Prognosis of surgically determined complete responders in advanced ovarian cancer

From January 1971 through December 1981, 246 patients with advanced (Stages III and IV) epithelial ovarian cancer underwent second-look laparotomy at The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston. Eighty-five of these patients had a complete response (negative second-look laparotomy) following treatment with a variety of chemotherapeutic regimens. Three patients had also received irradiation. Patients were analyzed according to pretreatment characteristics (age, FIGO stage, ascites, pleural effusion, histologic grade, tumor type, type of surgery, residual tumor diameter, initial clinical status) and by the number of biopsy specimens taken at second-look laparotomy. The probability of recurrence and the length of survival following a negative second-look laparotomy are statistically related to these characteristics. Twenty of the 85 patients (24%) developed recurrent disease 5 to 32 months after laparotomy. The estimated 2- and 5-year survival rates are 99% and 85%, respectively. Patients who achieve a surgically determined complete response have an excellent chance for long-term survival.

Microscopic disease at second-look laparotomy in advanced ovarian cancer

During the 11-year interval from January 1971 to January 1982, 50 of 246 patients with advanced (Stage III and IV) epithelial ovarian carcinoma at second-look laparotomy had biopsy or cytologic evidence of persistent microscopic carcinoma. The stage and grade profile include 46 Stage III and 4 Stage IV patients: 4 borderline, 9 grade 1, 20 grade 2 and 17 grade 3 patients. Following second-look laparotomy, 4 patients received no further therapy, 45 received chemotherapy, and 1 received external radiation. No patient was lost to follow-up, and the median interval off therapy was 24 months. Progressive or recurrent disease has manifest in 12 (24%). No recurrences have developed either in patients younger than age 40 or in patients with grade 1 tumors. Two patients died of leukemia, 1 died of heart disease, and 35 (70%) are alive with no evidence of disease. In patients developing recurrence, the median progression-free interval was 17.5 months, with a range of 6 to 46 months. The median interval of survival following disease progression was 7 months. There was no evidence of progression at 2 years and 5 years in 81% and 70% of patients, respectively. The uncorrected 2- and 5-year survival rates were 96% and 71%, respectively. The 5-year survival rates for grades 1, 2, and 3 were 100%, 79%, and 36%, respectively. Other variables analyzed include number of positive foci, residual tumor volume at initial surgery, cytologic findings at second-look laparotomy, type of chemotherapy, and number of courses of chemotherapy before second-look laparotomy. In summary, patients with only microscopic evidence of disease at second-look surgery have a good probability for extended survival.

Second-look laparotomy in fallopian tube carcinoma

From August 1974 through August 1980, eight patients with primary fallopian tube carcinoma underwent second-look laparotomies at The University of Texas M.D. Anderson Hospital and Tumor Institute. Prior to the second-look laparotomies all patients were clinically free of disease. Initial treatment consisted of surgery and chemotherapy for four of these patients, surgery and radiation therapy for two patients, and surgery, radiation therapy, and chemotherapy for two patients. The second-look laparotomies showed five patients were free of disease, one patient had microscopic residual disease, and two patients had persistent macroscopic disease. Recurrences following negative second-look laparotomies developed in two patients. One recurrence occurred at 41 months after the procedure and the other 69 months afterward. Both patients lived more than 5 years after the second-look laparotomies were performed. Three patients with negative findings at second-look procedures and the patient with microscopic residual disease remain clinically free of disease 34, 53, 74, and 50 months after the laparotomies, respectively. Following additional chemotherapy, the two patients who evidenced macroscopic disease at the second-look procedure died 16 and 32 months following the second-look laparotomies. The second-look findings can be used to predict disease behavior and may have a role in the management of patients with fallopian tube carcinoma.

Second-look laparotomy in epithelial ovarian carcinoma: precise definition, sensitivity, and specificity of the operative procedure

Twenty-five women treated with chemotherapy for epithelial ovarian carcinoma underwent "second-look" laparotomy after thorough clinical and radiographic examinations failed to detect residual tumor. Chest roentgenogram, barium enema, upper gastrointestinal series with small-bowel follow through, and abdominopelvic CAT scan were obtained in all patients prior to operation. Inspection, palpation, and multiple biopsies were performed in accordance with precise and detailed protocol requirements. Eight patients (32%) had gross tumor found at laparotomy, while 6 (24%) had no suspicion of residual disease at operation but had cytologic or microscopic evidence of tumor found on review of submitted specimens. Eleven patients (44%) had no gross or microscopic evidence of residual ovarian carcinoma. After follow-up of from 4 to 25 months, 1 of these 11 patients (9%) has suffered a recurrence. The maximum sensitivity of "second-look" laparotomy is 85.7%, and the maximum specificity is 90.9% in this series. Any additional recurrences observed over time will decrease both the sensitivity and specificity of the operation. The sites of microscopic disease support rigid adherence to a precise operative procedure which should minimize the false negative rate.

Analysis of sites of persistent cancer at "second-look" laparotomy in patients with ovarian cancer

Forty-two patients with ovarian cancer underwent "second-look" laparotomy to determine disease status. Seventeen patients were free of disease; 15 demonstrated tumor regression, but microscopic (3) or macroscopic (12) cancer persisted; and 10 had progressive disease. A significantly increased correlation between positive biopsy sites at second look and sites of known initial residual cancer was noted (76.7% versus 42.3% total positive), particularly in patients with minute disease, at second look. This correlation increased (85.3% versus 64.8%) when both the initial tumor reduction and documentation of residual disease and the second-look procedure were performed by the same surgeon. No such difference was noted in patients with progressive disease. In no instance was disease found at new sites when sites of previous residual cancer were disease free. These results underscore the need for accurate documentation of residual tumor after initial tumor reduction in order to direct the biopsy pattern more accurately, particularly in patients with minute or microscopic disease at second look.

Surgery following initial treatment of ovarian carcinoma: restaging (second-look) and palliative operations

Of 73 patients treated for ovarian carcinoma at the University of Nebraska Medical Center between 1976 and 1982, 37 underwent a second operative procedure following initial surgery. A total of 14 had a second look following complete clinical response, 11 had intestinal diversion, and 12 underwent other procedures. Second-look surgery proved useful in evaluating patients in clinical remission and directing subsequent management. The majority of patients whose operations were for persistent or recurrent disease had short survival. However, such surgery helps occasional patients and should be considered when circumstances warrant.

Reexploration after treatment for uterine sarcoma

Eleven patients treated with combination chemotherapy and radiotherapy for uterine sarcoma were reexplored after an interval of therapy. In none of the eight patients who were free of persistent sarcoma at the time of reexploration, did tumor recur during the period of follow-up. Two patients had all macroscopically visible residual sarcoma resected at reexploration and remain free of disease. The second-look laparotomy after a period of therapy may provide valuable prognostic information for planning therapy for patients who have metastatic or locally recurrent sarcoma.

Second-look operations in the planned management of advanced ovarian carcinoma

Second-look operations were done in 65 patients as part of a planned management program of advanced ovarian cancer. All patients received chemotherapy with cisplatin, and only those who had a good clinical regression after an incomplete initial surgical procedure were subjected to a second operation. At second-look operations, 16 patients (25%) had no macroscopic tumor (surgical complete remission), and these patients have a 72% probability of surviving 5 years. In 49 patients (75%), considerable regression had occurred but macroscopic disease was still present. Incomplete or complete removal of residual disease was possible in 38 cases (58%), but survival curves suggest that removal of all macroscopic residual disease at second-look operations did not improve survival expectancy. In the other 11 cases (17%), although there was slight improvement in the extent of disease, further surgical resection was not possible and the survival expectancy in these cases was very poor.

The place of surgery in the management of ovarian cancer

One hundred and eighty-eight patients with ovarian cancer treated at the Mater Hospital gynaecological radiosurgical unit, Brisbane are surveyed. The place and results of different surgical techniques are assessed and related to pathology findings. Although significant improvement of results can be obtained with meticulous assessment combined with aggressive surgery and subsequent chemotherapy and radiotherapy, the 5-year survival rate (34%) remains disappointing.

The changing role of "second-look" laparotomy in the management of epithelial carcinoma of the ovary

Thirty-seven of 137 patients had a "second-look" laparotomy in the course of their management of carcinoma of the ovary. Patients were stratified according to three indications: (1) evaluation of disease with intent of stopping therapy, (2) assessment of signs of recurrent or persistent disease with a view to debulking tumor mass and changing chemotherapy, and (3) further tumor resection following cis-platinum combination therapy and determination of further chemotherapeutic agents. "Second-look" laparotomy may be performed after a shorter time interval when combination therapy is given because of the dose-limiting side effects of some of these agents and a more aggressive surgical approach in debulking tumors. At the time of laparotomy, cytologic testing is performed on the peritoneal fluid, and only areas suspicious for malignancy are biopsied. Thirteen percent of patients with no evidence of disease at "second-look" laparotomy developed recurrent disease. Twenty-nine percent of patients classified as clinically free of disease had malignancy present at the time of operation. Continued routine use of "second-look" laparotomy after appropriate chemotherapy is recommended.